Summary On the afternoon of 15 May 2002 at approximately 1700 eastern daylight time, the workboat 36E33460 was being used to transport a roofing crew of four and a cargo of used shingles from a construction site on Anstruther Lake, Ontario. In mid-lake, the deeply-laden vessel began taking water over the bow. Shortly thereafter, the vessel swamped and sank. The four roofers swam to shore. The operator drowned. Ce rapport est galement disponible en franais. Other Factual Information Particulars of the Vessel Description of the Vessel The vessel was of welded steel construction with a single hard chine at the turn of the bilge. Two bench seats were built into the vessel which incorporated steel buoyancy chambers underneath. The bow was flat with a slight rake aft. The operator sat aft on a swivel seat adjacent to the outboard motor. Description of the Voyage In early spring of 2002, a roofing contractor (the contractor) obtained a contract to re-roof two cottages on Anstruther Lake. As the cottages were located in a remote location accessible only by water, the contractor made arrangements with a local commercial barge service operator (the operator) to transport material, tools and 12personnel to and from the job sites. At 0700 eastern daylight time2, on the day of the occurrence, the roofing material, consisting of 105bundles of asphalt shingles, was loaded on a motorized barge and transported to the job sites by the operator. While the barge was being loaded, the operator transported six roofing personnel to the job site in the workboat. Upon his return, he delivered the barge-load of material, while the owner of the roofing company used the steel workboat to transport the remaining roofing personnel to the job sites. At approximately 1500, the operator transported a load of used shingles in a dump trailer on the barge from the job sites to the government landing. Leaving eight workers to finish up the remaining roofing work, the contractor took three employees back to the landing to offload the barge and transport the used shingles to the local landfill. Simultaneously, the operator transported four roofing personnel back to the landing and returned for the remaining debris, tools and four employees, arriving at the job site at approximately 1630. The vessel was loaded with used shingles up to the level of the gunwales in the centre between the seats, and in the area forward of the seats, until a freeboard of approximately 0.2metre (m) remained. Two aluminum ladders, two bundles of new shingles, and roofing tools were also placed on board. The roofers expressed reluctance to board the heavily-laden workboat, however the operator reassured them that the boat had previously been similarly loaded. The operator, his dog and four roofers departed the work site at 1700, and as the boat entered the open waters of the lake and turned south-west into the prevailing wind and waves, it began to take water over the bow. In an effort to reduce the amount of water coming on board, the operator increased speed in an attempt to raise the bow. The vessel continued at higher speed for five to ten minutes and then suddenly slowed. The bow immediately dropped and descended into an oncoming wave, which swamped the boat. The vessel began to capsize to port and simultaneously sank by the bow kilometre from shore, in 20m of water. When the vessel sank, two personal flotation devices (PFDs), two seat cushions, a gas can and the plastic bin containing the PFDs floated free. The operator was thrown a PFD, however he was not seen to don it. Two of the roofers used the seat cushions to float on, one used the gas can, and the last used the plastic bin for flotation. The roofers, following the lead of the owner's dog, decided to swim to a nearby island, however the operator indicated that he would rather try to reach the opposite, more rocky shoreline. As the roofers swam away they became separated from each other and the operator. Two of the roofers reached the island first and huddled together to stay warm. It is estimated that they had been in the water for hour before reaching the shore. The third roofer reached the island in a more advanced condition of hypothermia than the first two, after being in the water approximately 40minutes. Once on the island, one roofer decided to swim the short distance (70m) to the mainland to call for help from a cottage. At this point, the fourth roofer had not been accounted for. Search and Rescue Upon returning from the landfill site at 1700, the roofing contractor noticed that the operator had not yet returned with the remaining roofers. At 1720, he and an employee decided to take a 4m aluminum boat to search for them. After visiting the job sites, and the operator's lake-front home, the roofing contractor began a search of the lake at 1800. Within 10minutes, he spotted and recovered the final member of the roofing crew floating on the gas can, and dragged him to the nearby island. After the other three survivors on the island were located, they were transported by boat to the nearby cottage on the mainland and treated for hypothermia. At 1834 the contractor called his girlfriend from the cottage and requested that she call 911 for help. At 1850, once the survivors were safely sheltered in the cottage, the roofing contractor proceeded to search for the operator. Within 10minutes, the operator was found partially submerged, with his arm through a PFD, approximately 150m from the south-east shore opposite to the island. He was immediately pulled to shore where cardiopulmonary resuscitation (CPR) was begun. Shortly thereafter, a team from the North Kawartha Fire and Rescue service arrived to assist, however the operator could not be revived. Three of the four roofers were transported to the Peterborough regional hospital for observation. The fourth declined treatment. The Peterborough coroner determined the cause of the operator's death to be hypothermia and drowning. Inspection by Ontario Provincial Police Search and Recovery Dive Team On 16 May 2002 the Ontario Provincial Police Search and Recovery Unit located the vessel in 20m of water, recovered the fuel tank to prevent pollution, and marked the wreck location with a buoy. The Ontario Provincial Police returned the following day with a Transportation Safety Board of Canada (TSB) investigator to document the disposition of the vessel on the bottom. An underwater video was taken of the vessel which showed that it was in an upright position, partially embedded in the bottom sediment. Used shingles were piled in the forward and midships areas to a level above the gunwales. The outboard motor control was engaged in the ahead position with the throttle wide open. Although various possibilities exist, the reason for this cannot be determined. Built in buoyancy tanks located under the seats were partially crushed by the water pressure. Environmental Conditions At the time of the occurrence, the weather was clear and sunny with a temperature of 25C. Winds were gusting to 25km/h from the south-west. The wave height was estimated to have been 0.6m. The surface water temperature was 8C at the site of the occurrence. Lifesaving Appliances and Passenger Safety Briefing It is reported that the vessel carried PFDs, stored in a plastic bin, however neither the bin, nor the PFDs were located. In addition, two PFDs, the owner's anti-exposure work coat and two buoyant seat cushions were available near the passenger seats. On 01May2002, an amendment to the Small Vessel Regulationscame into force requiring passenger safety briefings on small passenger vessels. No formal passenger safety briefing was carried out, however it is reported that the operator pointed out the location of the PFDs to the passengers. Notwithstanding this, when the vessel sank, one survivor used the bin itself for flotation; he and the other survivors being unaware that the plastic bin contained PFDs. Regulations pursuant to the Occupational Health and Safety Act of Ontario3 governing construction projects require that any worker who is at risk of drowning must wear a lifejacket. Further provisions for construction projects require that workers be trained to perform rescue operations and that there be a means of warning workers at risk. It is not clear whether these requirements would extend to the carriage of workers in a vessel to and from a construction site. Certification of Vessel and Operator Information obtained from Canada Customs in Peterborough, Ontario indicates that the vessel was licensed to the operator in July,1990 however the license issued does not indicate the intended use of the vessel. The steel vessel's licence however indicates that it is constructed of aluminum. If a ship is chartered by an employer to transport workers to or from a work site, the employees are considered passengers ...4 As a result, the roofing crew being carried by the vessel on the day of the occurrence are considered to be passengers, and the vessel involved in the occurrence was operating as a small passenger vessel. Due to its size (under 15gross registered tons [grt]) and the number of passengers carried (12orfewer) the vessel was not subject to compliance with the Hull Construction Regulations or the Hull Inspection Regulationsmade pursuant to the Canada Shipping Act. However, it was subject to compliance with other regulations, including the Small Vessel Regulations, in particular the safety equipment carriage requirements. As a commercial passenger vessel under 15 grt carrying not more than 12passengers the workboat was subject to the requirements of the Small Vessel Monitoring and Inspection Program (SVMIP), that evolved from the Interim Small Passenger Vessel Compliance Program (ISPVCP).5 The SVMIP is a voluntary compliance program in which all small vessel owners and operators are encouraged to adopt a self-monitoring inspection regime. In this manner, they can ensure that vessels are in compliance with the safety requirements that pertain to their operation. The perception within Transport Canada (TC) however is that the SVMIP, being a program and not a regulation, cannot be enforced. At the time of the occurrence, TC was not aware that the vessel was engaged in commercial work or in transporting passengers and it had not been inspected by TC. The operator had extensive experience on the water and was a longtime resident of Anstruther Lake, but held no marine certificate of competency nor was he required to under the Crewing Regulations.The operator was however required to have undertaken Marine Emergency Duties training. The owner of the roofing company had no formal marine experience. Provincial Initiatives In February 1998, in the interests of the safety of passengers travelling on small uninspected passenger vessels, the Province of Quebec passed a decree6 requiring all small passenger vessels under 5grt and carrying 12or fewer passengers to be inspected (by a professional surveyor approved by TC) and to carry at least one million dollars of liability insurance. The survey includes inspection of the vessel as well as boarding and landing sites. The surveyor will issue a letter of compliance stipulating that the vessel meets TC regulatory requirements and is appropriately equipped to operate a safe service (as described in the surveyor's report), and that the operating crew is knowledgeable to conduct the specified commercial activity in a specified area/territory. The provincial Commission des transports du Qubec then issues a permit to the operator. Prior Occurrences On 03 December 2001, a small commercial workboat carrying five construction workers on Lac des Deux Montagnes, Quebec, was swamped and sank, causing three fatalities. The vessel had not been identified by TC or inspected as a commercial vessel, nor had the owner requested the inspection. Investigation by the Quebec provincial Commission de la sant et de la scurit du travailrevealed that the workboat lacked reserve buoyancy, that the available rescue boat was not suitably equipped, that the cold water conditions contributed to the fatalities and that the passengers were not wearing lifejackets. On 22 March 1998, the small passenger vessel OceanThunder7, with one operator and three passengers on board, capsized off Tofino, British Columbia. The Board found, interalia,that the operator did not fully appreciate the conditions the boat would meet at the time of the accident, and that the absence of emergency communications equipment delayed the search and rescue response. The Board expressed concern that, because current regulations did not reflect the need for thermal protection, mariners and passengers on small vessels may be exposed to undue risk from hypothermia.